1. Technical Field
The present invention relates to communication between data processing systems. In particular, the present invention relates to direct communication of healthcare administrative information and related data between service provider computer systems and payer computer systems.
2. Background Information
Accurate, rapid, and reliable payment of invoices is crucial to every business. When a business generates a consistently large volume of invoices claims, or other transactions, a significant amount of income may become snarled in complex automated claim submission and payment mechanisms. For example, a hospital or other health care provider may have at any given time many hundreds or thousands of claims pending for payments totaling hundreds of thousands or millions of dollars.
Healthcare service providers spend a large quantity of time and effort communicating administrative transactions with health insurance companies. These transactions can include claim submission, member eligibility verification, claim status checks, coordination of benefits with third party payers, remittance advice for final disposition of claims, and notification of payments.
In the past, many providers found that their administrative transactions were unduly delayed because third party clearinghouses handled the transactions. For claim submissions, for example, the clearinghouses acted as middlemen through which claims flowed, with additional processing, to connect payers and providers. Although clearinghouses attempted to address the need for accurate, rapid, and reliable submission of claims, the clearinghouses were often implemented with dated technology that could not meet or perform at acceptable service levels. In addition, the clearinghouses were costly to both the provider and the payer, not only because the clearinghouses took a commission on every claim processed, but also because the clearinghouses sometimes took days to electronically submit claims, failed to communicate claim rejections to the provider, and submitted duplicate and “dirty” claims.
Due in part to the disadvantages of clearinghouses, some business turned to administrative transaction portals, including claim portals. A transaction portal provides a submission interface for the provider into the payer. However, transaction portals were not linked into the providers practice management systems and therefore required time consuming, costly, and error-prone duplicate data entry into the portal. In addition, any response from the payer through the portal required additional processing to be recognized by the payers practice management system. Furthermore, each transaction portal was payer specific and therefore created significant process and change effort for providers.
A need has long existed for addressing the problems noted above and others previously experienced.